REQUEST FOR EXPRESSIONS OF INTEREST

Transcription

1 REQUEST FOR EXPRESSIONS OF INTEREST Attachment C: EOI Submission Template headspace National Youth Mental Health Foundation Ltd is funded by the Australian Government Department of Health and Ageing under the Youth Mental Health Initiative Program.

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3 EXPRESSION OF INTEREST To undertake the Lead Agency role in the establishment of a headspace centre: headspace Location: Lead Agency Name: Contact 1: (Name & Title) Telephone 1: 1: Contact 2: (Name & Title) Telephone 2: 2:

4 How to complete the submission: Please make sure your responses strictly adhere to the designated page/word limits and use a font size no smaller than 10 point Arial. Please keep your responses in the same order as that presented in the EOI Template. NOTE: unsolicited information will not be considered by either the headspace Evaluation Team or the headspace Project Team INCORPORATED ORGANISATIONS NOTE: You will be required to include with your submission: 1. A copy of your Certificate of Incorporation 2. A copy of audited financial statements for the previous two financial years, or an audited profit/loss statement for the previous two financial years as well as copies of Annual Reports for those two years. headspace centres: Expression of Interest Submission Template: Round Four Page 4 of 13

5 1. APPLICANT DETAILS Legal Name of Lead Agency Trading Name of Lead Agency (if applicable) Australian Company Number (ACN) Australian Business Number (ABN) Not-for-profit Organisation Charitable Organisation Health Institution Type of Organisation Educational Organisation Aboriginal or Torres Strait Islander Organisation Private Practice Other (please specify) Street Address Postal Address Contact Person Position/Title Telephone Number Fax Number Address headspace centres: Expression of Interest Submission Template: Round Four Page 5 of 13

6 2. RESPONSES TO EOI CRITERIA 2.1 EOI Criteria 1 Articulation of the local vision for how a headspace centre will be established, including demonstrated understanding of the headspace model, anticipated challenges, and local strengths that will assist the establishment of the centre. (Maximum 750 words) headspace centres: Expression of Interest Submission Template: Round Four Page 6 of 13

7 2.2 EOI Criteria 2 Please outline your organisational values, and how they are compatible with those of headspace. (Maximum 500 words) headspace centres: Expression of Interest Submission Template: Round Four Page 7 of 13

8 2.3 EOI Criteria 3 Demonstrated expertise and experience in managing the clinical, operational and financial aspects of a health service Clinical Expertise and Experience (Maximum 500 words) Operational Expertise and Experience (Maximum 500 words) Financial Expertise and Experience (Maximum 500 words) headspace centres: Expression of Interest Submission Template: Round Four Page 8 of 13

9 2.4 EOI Criteria 4 Confirmation of commitment to co-locating or otherwise contributing the equivalent of 1 FTE of staff time from the respondent organisation to enhance the capacity of the proposed headspace service. (Maximum 250 words) 2.5 EOI Criteria 5 Demonstrated support from other prospective consortium members including agreement in principle to co-locating or otherwise contributing the equivalent of 0.2 FTE of staff time from each prospective consortium member to enhance the capacity of the proposed headspace service. (Maximum 250 words) headspace centres: Expression of Interest Submission Template: Round Four Page 9 of 13

10 3. REFEREES Please provide contact details for two referees who are familiar with your organisation/work. Name: Position/Title: Organisation: Relationship to Lead Agency: Length of time of relationship to Lead Agency: Contact Phone: Contact Fax: Contact Contact Mobile: Name: Position/Title: Organisation: Relationship to Lead Agency: Length of time of relationship to Lead Agency: Contact Phone: Contact Fax: Contact Contact Mobile: headspace centres: Expression of Interest Submission Template: Round Four Page 10 of 13

11 4. AGREEMENTS 4.1 If our organisation is successful, we agree that a description of the project, amount of funding and organisation may be: used in media releases and other publications; provided to organisations or individuals with a view to them contacting me for further information; and used to compile a consolidated report. YES NO 4.2 We understand that if our application is short-listed we will make time available for headspace to meet with consortium members to discuss our application in further detail. YES NO 4.3 We understand that in the event that this application for funding is successful, we may be required to produce proof that the organisation making this application has sufficient insurance cover to conduct the proposed activities specified in this application form. YES NO headspace centres: Expression of Interest Submission Template: Round Four Page 11 of 13

12 5. ENDORSEMENT In signing this, the organisation that has been cited in this submission as the lead agency confirms its commitment to the process and that the information provided is complete and correct. Signed for and on behalf of <Lead Agency Name> by its authorised representatives: <Signature> <Signature> <Position title - Chief Executive Officer or equivalent> <Position Title - Chairperson of the board or equivalent> Name (please print) Name (please print) headspace centres: Expression of Interest Submission Template: Round Four Page 12 of 13

13 6. CHECKLIST Please complete this checklist before lodging your submission. Before you begin Attend an Information Session run by headspace (optional). Read the Background Information document (available on the headspace website). Completing your submission Ensure that in completing your submission you have: Named the organisation applying for the funding. Nominated a contact officer in this organisation. Included letters of support from the other organisations supporting this proposal For incorporated organisations: Lodging your submission Include one (1) copy of your Certificate of Incorporation Include one (1) copy of your audited financial statements for the previous two financial years, or an audited profit/loss statement for the previous two financial years, as well as copies of Annual Reports for those two years. For all organisations: Check that all relevant sections of the submission have been completed Include contact details for two (2) referees headspace centres: Expression of Interest Submission Template: Round Four Page 13 of 13